HomeMy WebLinkAbout1005A 'vORKERS'COSIPENSATIONDECLARATION ' 76A663 APPLICATION FOR ELECTRiCAL PERMIT �j �
�� � � '� CE-806G 12-80) .
:reby aftirm �hat i have a certificate of consem m seit ; COUNTY OF LOS ANGELES BUILDING AND SAFETY L�
.iure,or a certificate ol Workers'Compensation Insurance,or I .
�a certffied copy thepre,�oyf�( c.3800,Lab.C.) ' � � �
�a�����7� ���zo�. � FORAPPLICANTTO FILL IN �pg n }�
�. Policy No. �Company EACH NO. FEE ADDRESS�C O (l
New Residential Bldgs.&Poots
�Certified cnpy is hereby turnished. 1&2Family,Sq.Ft.� $ — S LOCALITV p - �,�-�
Multi•family Sq.Ft, NEAR
r❑'"Certified copy is tiled with ihe county building inspection ' � CR055 57 �
department. Residential Swimming Pools � OWMEA OR �w�n�Q�
FIRM NAME L/'u�J�iW ��S T
Date Applicant Outlets:Rec.,_Light_Sw._ � MAIL
Firs[20 ADDRESS ..Z� 'r'
CIRTIPiCATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY
COMPENSA7ION MSURANCE � � �/�jyryJ M��s,zt/Fel No.�� � ��G¢
� � PLAN CHECK a
APP�ICANT
(This section need not be completed if the work involved Li9hting Fixtures First 20 V
�by the permit is for one hundred dollara (SI00)or less.), nDDREss
Total No. � Additional �
I certify that in the performance of the work Fnr avhich this Fixed Appliances Not Over 1 HP CITV Tei No. ` Q
permit is issued,1 shall not empiny sny person in any manner PERMIT V
so as to become subject.to the Workers'Compensation Laws. Range_Heater_�.W._ APPLICANT �y
� Oven _Dryet_W.M._ � a
. ADDHESS�f' �
Uate Applicant Top _FAU _W.H.._ _ wE �Z
Hood_Fan _Other_ � CITI' Ta1No. r ^ ,j
NOTICE TO APPLICANT:If,after making ihis CerUficate nf Disp. _Room Air Cond� LICEnIse O r .
Exemption, you should become subject to the Workers' . REG.NUMBER Claa �
Compensation provisions of Ihe Labor Code,you must for[h- power Appa�atus&L.arge Appliances DIS7RICT NO. PROCES�BY �
with comply with such provisions or this permit shall be Size&Type HP,KW,KVA,or KVAR " /G7 ��� �
deemed revoked.
� Up to 1 Incl.
FINAL
� Ovef 1 t01D IOCI. DATE �( � ,}� , VALIDATION
UCENSED CONTRACTORS D6CLARATION Over 10 to 50 Inel. � �' �"
I hereby atfirm that 1 am Iicensed under provisfons of Chapter Over 50 to 700 Ine. - FINAL -
9(Commencing avith SeCtion 7000)of Division 3 ot the Husl- - Bw � �
ness and Professions.CoJe,and my license is in full force and- Over 100 I�'���'l� 1 CZt;—'�--� .
1
effect. � Services �
License Numbe=��, Lic.Class �-z00 Amp.Under 600 V � �
/� �� ����1 201-1000 Amp.Under 600 V
ContractoF4E�.� pate� � � �� Over 7000 Amp.or Over 600 V . - .
HO�fE OWN�R-BUILDER DECLARATION Temp.Power Pole&Appurtenances � ��`Gt
1 hereby affirm that I am exempt frnm the Contractor's Sign with One Branch Circuit , �
• License Law fm Ihe foltowing reacnn(Sectinn 7n31.5,a���i. Additianal Sign Brench Circuits ' . �� O Q S A�
ness and Professions Code): - -�� � � �'�2
Misc,Conduits&Conductors �
� t, as o�vner of the property.�will do the�vork and the pthe $¢e o ple Fee Schedule)— + • •C Q Jr O �
structure is not intended or offered for sale (Section - '
70a4,Business and Pmfessions Cade). � • • •2 a 5 Q�
� CONSTRUCTION LCNDING AGf•.NCY �
I hereby affirm that there is a construction lending agency �
for the performance�of the work for which ihis permit is pERMITFEE (Sub•Total� (1 �z� 4-8�� ,
issued(Sec.J097,Civ.C.). " . U
Lender's Name PLAN CHECKING FEE IOne•Fourth Permit Fee1 - . .
Lender's Address PERMIT ISSUING FEE � � (� � �
[certify that 1 have read this application and state that the TOTALFEE . �O jL .
a6ove Information is correct.1 agree to comply with atl Co�mty � .
nrdinances and State laws regulating Elecitical wiring, and � �
hereby authorixe representatives of this County to enter uP�n � . . ' �
the above-mentiope�op y^or inspection purpo� SEE'RBVERSB FOR EXPLANATORY.LANGUAGE
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Signature of Permittee ate � � -
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